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Y,Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. FOR OFFICE USE' - APPLICATION r For Non-Transferable, Revocable, Suspendable ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is II made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application i made in compliance with San Joaquin County Ordinance No. 1I3a�the rules and regulations of the San Joa uin Local Ith District. Exact Site Address_Spit11111> ^� s Owner's Name City/Town K If Address Phone Contractor's Name C �rr+ City Contractor's Address 4 License#�� Business Phone Is Certificate of Workman's Compensation In rance on File With SJLHDrnergYesy Phone A!/� —� TYPE OF WORK (CHECK): NEW WELL �— No DEEPEN WELL CHLORINATION ❑ ❑ RECONDITION C1 DESTRUCTION❑ t REPLACEMENT© WELL ABANDONMENT ❑ OTHER ❑" PUMP INSTALLATION IP UMP REPAIR❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy o Sewage Disposal Field all, Cesspool/Seepage Pit- Property Line / Other INTENDED USE � Private Domestic Well Public Domestic Well ❑ INDUSTRIAL TYPE OF WELL CABLE TOOL DOMESTIC/PRIVATE--- CABLE Dia. of Well Excavation 9—DOMESTIC/PuBLIC DRILLED Dia. of Well Casing b ❑ iRRIGATION ❑ DRIVEN Gauge of Casing 11 CATHODIC PROTECTION 11GRAVEL PACK Depth of Grout Seal ❑ DISPOSAL ROTARY Type of Grout ❑ GEOPHYSICAL OTHER Other Information PUMP INSTALLATION: Surface Seal Installed By: Contractor PUMP REPLACEMENT: Type of Pump PUMP REPAIR: ElState Work Done H.P. DESTRUCTION OF WELL: ❑ State Work Done Well Diameter Describe Material and Procedure Approximate Depth I hereby certif that I have repared this application and that the work will be done in accordance with San J ordinances, Ifc tat laws, an r les and regulations of the San Joaquin Local Health District. Joaquin County Home own ar nsed Bert's signature certifies the following: is issued, shall n t e loy ny person in such manner as to become subject to workman's compensatfy that in the performance of the ion rk for of California.!" Contra or's hirin o ub-c tracting slgnature es the following: permi is iss I Il ploy persons su ct to workman's compensation laws that Califoin the e n arrnance of the work for which this I will Il for a out I spe fon prior grouting and a final inspection. •igned X Title: (Draw Plot Plan on Reverse Side) Date: PHASE I FOR DEPARTM NT USE ONLY Application Accepted By Additional Comments: Date —1-2 Phase If nspectlon / sl Inspection By �1L�_� Phase F' I Inspection ate Inspection By Fee Is Due: ❑ ANNUALLY Date ❑ PER UNIT PEE?SITE ❑ EACH ❑ January I &Received By January 37 ❑ July 1 &Received By July 31 BASE EXPLANATION BILLING REMITTANCE DATEREMIT FEE DATE REMITTED AMOUNTDUE CHECKED � AMOUNT LESS PRORATION '7 PLUS PENALTY OTHER OTHER 1 r Received by Date APPLfCANT— Receip!No. Permit No. - 1 RETURN ALL COPIES Tp: ENVIRONMENTAL HEALTH PERMIssuance Date Mailed l Delivered 1